Anorectal diseases

Fracture of the tibia is a well-known, often occult cause of limping and leg pain in young children. This fracture is typically a hairline, oblique fracture of the shaft of the tibia, and in some cases the fracture can be so subtle that bone scintigraphy or follow-up radiography may be required for its detection. In addition, a variety of other fractures that are less well known and just as difficult to detect can occur in the tibia and the foot in young children. These fractures include plastic bowing and buckle-type fractures, especially of the fibula; impaction, compression, or stress (fatigue) fractures of the tibia and fibula; and fractures of the metatarsal and tarsal bones. All of these fractures can be remarkably similar to the non-displaced spiral tibial fracture in their clinical appearance and should be included under the rubric of "toddler's fracture."     

Conservative or operative treatment of fractures of the head of the tibia (author's transl)

Whether fractures of the head of the tibia have to be treated conservatively or surgically in an active way depends on the type of the fracture. In cases with small dislocation conservative treatment should be given priority. Only fractures with badly dislocated fragments should be operated on (osteosythesis).     

Evaluation of tibial plateau fractures: efficacy of MR imaging compared with CT

OBJECTIVE: CT is often used after plain films to evaluate fractures of the tibial plateau. Because MR imaging can show associated soft-tissue injuries as well as fractures, we hypothesize that MR is superior to CT for imaging these injuries. Accordingly, we compared the efficacy of MR imaging and CT in 22 patients with tibial plateau fractures. SUBJECTS AND METHODS: CT with two-dimensional reconstruction and MR examinations were performed in 22 patients with tibial plateau fractures. The images were interpreted by four radiologists and two orthopedic surgeons. Findings on CT scans and plain films were used to determine the configuration of the fractures and to classify them according to the Schatzker system. This was done with findings on MR images and plain films at a separate session. The MR images were also evaluated for ligamentous and meniscal injuries. A qualitative side-by-side comparison of two-dimensional CT scans and MR images for depiction of fracture configuration was done. Imaging results were correlated with observations from physical examinations in all patients and with surgical findings in 12 patients. RESULTS: All of the six types of fractures of the Schatzker classification were observed in this series. Comparison of two-dimensional CT reconstructions and MR images for depiction of fracture configuration revealed that the two techniques were equal in 14 patients, MR imaging was superior to CT in five patients, and CT was superior to MR imaging in three patients (who had very complex and comminuted fractures). In addition, MR imaging showed 12 complete ligamentous tears and 15 partial ligamentous tears in 15 (68%) of the 22 patients. MR showed meniscal injuries in 12 (55%) of the 22 patients. CONCLUSION: MR imaging was equivalent or superior to two-dimensional CT reconstruction for depiction of fracture configuration in most patients. In addition, MR showed significant soft-tissue injuries. We believe that MR imaging is the preferable imaging technique for most patients with fractures of the tibial plateau.     

The potentials of minimally invasive surgical measures in the knee joint

The treatment of knee joint injuries has seen marked development in the last few years. The surgical trauma of intra-articular fracture reconstruction has been reduced significantly. Retrograde nailing, percutaneous plating and specific exposures to distal femur and proximal tibia fractures have been established. Percutaneous osteosynthesis controlled by arthroscopy or fluoroscopy is widely used for B-fractures of the tibial plateau. Injectable bone mineral cement adds to reduced trauma of surgical treatment of these fractures. In all knee ligament procedures, arthroscopy is obligatory for diagnosing and conducting meniscus surgery. Ligament reconstruction should be performed either arthroscopically or by a limited arthrotomy, the results being comparable at present.     

The role of fixation of the fibula in open fractures of the tibial shaft with fractures of the ipsilateral fibula: indications and outcomes

To determine the indications for fibular fixation in cases of combined fractures of the tibia and fibula and the effect of fibular fixation on tibial healing, a retrospective study of open fractures of the tibial shaft with concomitant fibula fractures was conducted at a level one trauma center. Apparent indications for fibular fixation included the presence of a syndesmotic injury and location of fracture within the distal third of the fibula. No significant differences were found in the healing rates, incidence of nonunion and malalignment, or in the number of required subsequent procedures between patients who did and did not undergo fibular stabilization. These results suggest that fixation of the fibula in open fractures of the tibia and fibula has no effect on fracture healing or alignment. A randomized, prospective study is needed to properly validate these findings.     

A trypsin inhibitor trans-4-guanidinomethylcyclohexanecarboxylic acid 4-tert-butylphenyl ester suppresses the onset of DNA synthesis in Escherichia coli cells synchronized by phosphate starvation

The Resonant Frequency (RF) of the tibia is proportional to its stiffness. As a fractured tibia heals, its RF should increase. The RF was serially determined in 74 fractured tibias (205 examinations). These were subdivided by fracture location and fixation. Fast Fourier transform software generates the RF from data obtained with an instrumented impactor and accelerometer. The RF was normalized by expressing it as a ratio of the intact tibia. This ratio is called the tibial stiffness index (TSI). A 20 point tibial fracture score (TFS) quantitated the clinical and radiographic signs of healing. For each group the paired TSI and TFS were compared by regression analysis. Except for those fractures limited to the proximal fourth of the tibia, the TSI was found to correlate significantly (p = 0.0001) with the TFS. Fractures without fixation and those with unlocked, unreamed tibial nails showed very significant correlation of TSI with TFS (p = 0.0001). RF analysis was not useful in fractures with locked or reamed tibial nails. Examination of tibia with external fixation showed significant correlation (p = 0.02) of the TSI with the TFS.     

Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures

From 04/91 to 06/96 sixty-nine open fractures of the tibia were primarily treated on the day of the accident with unreamed nailing (UTN, Synthese). The distributions of fracture type according to the AO classification and of soft tissue injury according to Gustilo were as follows: fracture type: A: 28%, B: 52%, C: 20%; soft tissue injury: I: 30%, II: 28%, IIIA: 12%, IIIB: 12%, IIIC: 6%. Of the 65 fractures assessed 46 (71%) healed within 18 weeks without secondary intervention. There was delayed healing in three fractures requiring secondary conversion to reamed nailing. Eight fractures (12%) developed pseudarthrosis of which five (8%) healed uneventfully. Deep infections was manifest in four fractures (6%). Three of these infections developed after secondary intervention to treat pseudarthrosis. Seven of the eight pseudarthroses and three of the four infections healed eventually. Revision procedures were necessary in 11 patients (17%) to deal with disturbed fracture healing or infection (10 reamed nailing procedures, three cancellous bone grafts, and one of each of the following: sequestrectomy, fibular osteotomy, plate fixation, external fixator, monorail procedure). The results show that the same good infection rates were achieved for the UTN as for the external fixator. The advantages of the UTN are, however, a lesser need for secondary intervention and greater patient comfort. Therefore, we find the UTN to be a good alternative to the external fixator in the treatment of open fractures with severe soft tissue damage.     

Comparison of the results of surgical and conservative treatment of fractures of the diaphysis of the tibia

In this paper is treated the fundamental problematic of the fracture of the diaphysis of the tibia and the therapeutic results after the conservative and operative treatment are confronted. Among 518 patients with 433 open fractures and 35 with closed fractures of the diaphysis of the tibia, successful treatment of more 2/3 was obtained in the period from 1968 to 1972. Following our casuistics and literature, whose results are similar, we find out that the average total treatment of the osteosynthesis of the fracture of the diaphysis was shortened for 2,5 months depending upon the type and the localisation of the fracture. Apolied methods of the operative and conservative and conservative treatment in relation to the velocity of the medical cure as well as to the extreme anatomical-functional results are analised. We noticed that osteosynthesis, made by the intermedullary nail and the extension of the canals or by a small AO table, by the achieved stability makes conditions of immediate motions and an early rehabilitation. Because of that it gives the best functional results.     

The increase in blood pressure induced by inhibition of nitric oxide synthase in anesthetized Wistar rats is inversely related to basal blood pressure value

A marked reduction of 40-70% in regional bone mineral density (BMD) has been reported after fractures of long bones, and this post-traumatic osteopenia may to some extent persist for several years, perhaps lifelong. In this cross-sectional study, we investigated whether prolonged alcohol abuse had any effect on the degree of post-traumatic osteopenia after isolated tibia shaft fractures, the rationale for such a suspicion being the deranged bone metabolism found in alcoholics. We also wanted to investigate whether dual energy X-ray absorptiometry (DEXA) or quantitative ultrasound technique could detect differences between abusers and non-abusers in post-traumatic bone loss. We measured the BMD in 61 male patients with isolated tibia shaft fractures (1984-94) with the Lunar DPX-L and the Lunar Achilles. Twenty-four of the patients were verified to be high consumers of alcohol. After correction for differences in age and the time elapsed since the fracture event, we found significantly lower (11%; P = 0.017) BMD in the femoral neck of the fractured leg in abusers when utilizing the DEXA technique. No differences between abusers and non-abusers in BMD were detectable when using the ultrasound technique. We found a fair correlation (r = 0.63-0.81) between the DEXA and the ultrasound techniques in regions with spongious bone. Our findings suggest that alcohol abuse has some, albeit a limited, effect on the degree of post-traumatic osteopenia and that ultrasound measurements in the calcaneus are of little use in detecting an increased post-traumatic osteopenia in this patient group.     

Minimally invasive knee joint surgery

The treatment of knee joint injuries has seen a marked development. Arthroscopy is standard for diagnostic purposes, for meniscus resection and meniscus refixation. Anterior cruciate ligament reconstruction may be performed mini-invasive by arthroscopic or mini-open technique with comparable result. Drill guide systems and fixation techniques allow for precise and stable graft placement. Posterior cruciate ligament surgery is presently undergoing a similar process of optimisation as ACL surgery has some years ago. The surgical trauma of intraarticular fracture reconstruction was also reduced significantly. Retrograde nailing, percutaneous plating and specific exposures to distal femur and proximal tibia fractures have been established. Percutaneous osteosynthesis controlled by arthroscopy or fluoroscopy is widely used for B-fractures of the tibial plateau. Injectable bone mineral cement adds to reduced trauma of surgical treatment of these fractures. Mini-invasive knee surgery will develop rapidly in the coming years.     

A study of intrinsic factors in patients with stress fractures of the tibia

We aimed to study intrinsic factors in 29 consecutive patients with well-documented unilateral stress fractures of the tibia. Anthropometry, range of motion, isokinetic plantar flexor muscle performance, and gait pattern were analyzed. The uninjured leg served as the control. A reference group of 30 uninjured subjects was compared regarding gait pattern. Anterior stress fractures of the tibia (N = 10) were localized in the push-off/ landing leg in 9/10 athletes, but were similarly distributed between legs in posteromedial injuries (N = 19). Ten (30%) of the stress fracture subjects had bilateral high foot arches, similar to those found in the reference group. There were no other systematic differences in anthropometry, range of motion, gait pattern, or isokinetic plantar flexor muscle peak torque and endurance between injured and uninjured legs. No other differences were found between anterior and posteromedial stress fractures. We conclude that anterior stress fractures of the tibia occur mainly in the push-off/landing leg in athletes. Within the limitations of our protocol, no registered intrinsic factor was found to be directly associated with the occurrence of a stress fracture of the tibia.     

Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age

Current knowledge regarding the basic epidemiology of fractures is largely limited to a few fracture sites, notably those of the hip and distal forearm. To clarify the patterns of incidence of limb fractures in the elderly, we used data from a 5% sample of the U.S. Medicare population over age 65 years during the years 1986-1990. We identified incident fractures of the proximal humerus, other parts of the humerus, proximal radius/ ulna, shaft of the radius/ulna, distal radius/ulna, pelvis, hip, other parts of the femur, patella, ankle, and other parts of the tibia/fibula from diagnoses and procedures coded on claims for inpatient services, outpatient facility use, and physician services. We used Poisson regression to investigate the relation between demographic factors and fracture risk at these sites. Fractures at the hip were the most common, accounting for 38% of the fractures identified. The proximal humerus, distal radius/ulna, and ankle also were common fracture sites. A pattern of rapidly rising rates with age was seen for fractures of the pelvis, hip, and other parts of the femur among women. Fractures distal to the elbow or knee, however, had, at most, modest increases in incidence with age over 65 years. For each of the fractures studied, women had higher rates than men of the same race, and whites generally had higher rates than blacks of the same gender. Gender-related differences in risk were larger among whites than among blacks, and racial differences in risk were more marked among women than among men.     

Vascular complications in injuries about the knee joint

In 1,377 patients who had severe injuries about the knee joint, vascular complications were present in 28 (2%). Injuries to the popliteal artery or its branches present serious problems. Amputation was necessary in 13 patients, and 12 patients had a Volkmann's syndrome. In fractures of the lower end of the femur or upper end of the tibia, and in knee dislocations, the importance of early diagnosis of the acute ischemic syndrome cannot be overemphasized. Tibial plateau fractures produced the highest percentage of vascular complications and indicate immediate application of therapeutic measures.     

Defective expression of early activation genes in cartilage-hair hypoplasia (CHH) with severe combined immunodeficiency (SCID)

PURPOSE OF STUDY: To examine factors which may predispose to tooth fracture, and to assess the compressive strengths of foods and sweets which are associated with tooth fracture in vivo. POPULATION STUDIED: Consecutive dental patients presenting with one or more fractured posterior teeth at the surgeries of three general dental practitioners, over a four-month period. METHOD: A pro forma was designed to elicit information on the factors associated with tooth fracture and the nature and extent of such fractures. Three general dental practitioners were requested to complete a pro forma for each patient presenting with a fractured posterior tooth over a four-month period. Foods and sweets considered to be associated with tooth fracture were identified and their compressive strengths tested. FINDINGS: A total of 129 cases of fractured posterior teeth were recorded, of which 48% occurred in the mandibular arch and 52% in the maxillary arch. In the mandible, 75% of tooth fractures occurred in molars while in the maxillary arch 50% occurred in molars. In 57% of cases assessed, no identifiable causative item was noted. Forty-five per cent of fractures were in teeth which had been restored on three or more surfaces. Compressive forces of 0.16KN to 2.2KN were obtained for food items implicated in tooth fractures. CONCLUSION: As mesio-occlusodistal restorations were identified as a major predisposing factor to tooth fracture in this study, with mandibular first molar teeth particularly affected, placement of cuspal coverage restorations may be considered to be a justifiable preventative measure in teeth identified as being at risk.     

Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof

OBJECTIVE: To review the risk factors and the radiological appearance of insufficiency fractures of the sacrum and acetabular roof. DESIGN AND PATIENTS: Twenty patients with sacral and acetabular roof insufficiency fractures were reviewed retrospectively. There were 16 women (80%) and 4 males (age range 48-86 years, excluding an 8-year-old boy). Thirteen patients had a known tumour, and nine had received pelvic irradiation. All patients, except one who was asymptomatic, presented with low back or hip pain. In patients with a known tumor, metastases were suspected. Plain radiography (20), bone scintigrams (16), MR examinations (20), and bone densitometry (14) were performed. Nine patients also each had a CT scan. RESULTS AND CONCLUSIONS: In three cases the CT scan performed 10-25 days after onset of symptoms was interpreted as normal. MR examination performed a few days after the CT scan showed in each of these three patients a fracture line with a band of edema. Scintigraphy was very sensitive, but the H-shaped pattern of sacral uptake, specific for an insufficiency fracture, was detected in only three of 16 cases. The earliest MR sign was medullary edema, seen as early as 18 days after the onset of symptoms. On spin echo (SE) T1-weighted images (T1WI), the hypointense signal of edema could mask a fracture line. On SE T2WI the fracture line could be detected within the hyperintense edema (10 of 17 patients with examinations including SE T2WI). However, in four patients a fracture of the sacrum was not seen on T2WI, these having been obtained in the axial plane. For this reason, intravenous gadolinium was injected, revealing a fracture line in 12 of 14 examinations, or fat suppression sequences were performed, revealing a fracture line in five of five cases. The total number of fractures detected was 17 [15 fractures of the sacrum (bilateral in 10 cases) and two of the acetabular roof]. At a later stage, the edema resolved and the fracture was clearly seen. The two cases of fracture of the acetabular roof were easily recognized at MRI, particularly in the sagittal plane.     

Heparin, low molecular weight heparin, heparinoid, and antithrombin III therapy of disseminated intravascular coagulation

OBJECTIVE: To determine features of fractures in young children that would be helpful in distinguishing child abuse from unintentional injuries. DESIGN: Case series. SETTING: Pediatric Services of Yale-New Haven (Conn) Hospital (a tertiary care center). PATIENTS: Consecutive children who were less than 3 years of age and who were examined for a fracture from January 1979 through December 1983 were identified from the daily logs of the emergency department or the hospital's child abuse registry. OUTCOME MEASURE: Each case was rated, by means of predefined criteria and a consensus of two clinicians and two pediatric radiologists, on a seven-point scale from "definite child abuse" to "definite unintentional injury." A middle rating of "unknown" was used if there was not enough information to reach a consensus. RESULTS: Of the 253 fractures in 215 children that were identified, we categorized 24.2% as abuse, 8.4% as unknown, and 67.4% as unintentional injuries. Fractures that were considered likely due to abuse were (1) fractures in children whose caretakers reported either a change in the child's behavior, but no accidental event, or a minor fall, but the injury was more severe than expected; (2) fractures of the radius/ulna, tibia/fibula, or femur in children less than 1 year of age; or (3) midshaft or metaphyseal fractures of the humerus. Linear fractures of the parietal bone were the most common skull fractures, whether due to abuse or unintentional injuries. CONCLUSION: In young children with fractures, child abuse is common. By comparing fractures due to abuse and those due to unintentional injuries, we obtained empiric evidence to help clinicians and radiologists correctly examine children with such serious injuries.     

Epidemiology and site specificity of stress fractures

Clinically, stress fractures appear to be a common overuse injury among athletes and in military recruits undertaking basic training; however, there is a lack of sound epidemiologic studies describing stress fracture occurrence in athletes. Few have directly compared stress fracture rates between sports to establish which poses the greatest risk for this injury. Furthermore, incidence rates, expressed in terms of exposure, have rarely been reported for stress fractures in athletes. Nevertheless, available data suggest that runners and ballet dancers are at relatively high risk for stress fractures. Although a gender difference in rates is clearly evident in military populations, this is less apparent in athletes. Other participant characteristics, such as age and race, may also influence stress fracture risk. The most common site of stress fracture in athletes is the tibia, although the site reflects the nature of the load applied to the skeleton. Stress fracture morbidity, expressed as the time until return to sport or activity, varies depending on the site. Generally, a period of 6 to 8 weeks is needed for healing; however, stress fractures at certain sites, such as the navicular and anterior tibial cortex, are often associated with protracted recovery and, in some cases, termination of sporting pursuits.     

Myocardial injury caused by an anaphylactic reaction to ampicillin/sulbactam in a patient with normal coronary arteries

OBJECTIVES: The study's objective was to examine incidence of fractures and associated activity restriction among children aged 0-12 years. DESIGN: Injuries were prospectively recorded over the four year period from 1992-95 in a cohort of children aged 0-12 years, representing 193,540 children years. Information about length and extent of activity restriction was collected from parents by a mailed questionnaire for a subsample of 192 children with a fracture. RESULTS: A total of 2477 fractures occurred in the study population (128 per 10,000 children annually). The incidence increased linearly with age, by 14 cases per 10,000 children year for each year of age. Boys and girls showed similar patterns of fracture occurrence. There was a significant difference in length of activity restrictions for different types of fractures. The mean and 95% confidence interval (CI) of activity restricted days for leg fractures were 26 (95% CI 7 to 45) days, for arm fractures, 14 (95% CI 8 to 20) days, and for other fractures, 5 (95% CI 1 to 8) days. Arm fractures represented 66% of the cases and 62% of the activity restricted days; leg fractures 19% of cases and 33% of all activity restricted days; and other fractures 16% of the cases but only 5% of the activity restricted days in this population. CONCLUSION: The incidence of fractures increases in childhood. Different types of fractures among children cause different amounts of activity restriction.     

Treatment with alendronate prevents fractures in women at highest risk: results from the Fracture Intervention Trial

BACKGROUND: The efficacy of antiresorptive therapy in preventing fractures in women at highest fracture risk, such as very elderly women or those with severe osteoporosis, is uncertain. PARTICIPANTS AND METHODS: Using data from a double-blind, randomized, placebo-controlled clinical trial that enrolled 2027 postmenopausal women aged 55 to 81 years with low femoral neck bone mineral density (BMD) and existing vertebral fractures, we examined the consistency of the effect of treatment with alendronate sodium in preventing fractures within a priori-specified risk subgroups defined at baseline by age, bone density, number of preexisting vertebral fractures, and history of postmenopausal fracture. The women were randomized to oral administration of alendronate or placebo and followed up for an average of 2.9 years. The initial dose of alendronate sodium was 5 mg/d; the dosage was increased from 5 to 10 mg/d at 24 months. New vertebral fractures, the primary end point of this arm of the trial, were defined by morphometry as a decrease of 20% and at least 4 mm in any vertebral height between baseline and a follow-up radiograph at 36 months. Incident clinical fractures, the secondary end point, included nonspine and clinical (symptomatic) vertebral fractures. All clinical fractures were confirmed with x-ray film reports or, in the case of clinical vertebral fractures, x-ray films. RESULTS: Overall, there was a 47% significant reduction in risk of new vertebral fractures in the alendronate group compared with the placebo group. The reduction in risk of new vertebral fracture was consistent across fracture risk categories including age (relative risk [RR], 0.49 in women < 75 years compared with 0.62 in those > or = 75 years), BMD (RR, 0.54 in women with a femoral neck BMD < 0.59 g/cm2 [median] compared with 0.53 in those with a BMD > or = 0.59 g/cm2), and number of preexisting vertebral fractures (RR, 0.58 in women with 1 vertebral fracture compared with 0.52 in those with > or = 2). The overall significant 28% reduction in risk of incident clinical fractures in the alendronate group compared with the placebo group was also observed within these subgroups. Compared with the number of lower-risk women, a similar or smaller number of high-risk women needed to be treated to prevent 1 fracture. For example, 8 women aged 75 years or older compared with 9 women younger than 75 years, or 4 women with 2 or more existing vertebral fractures compared with 16 women with 1 existing vertebral fracture, needed to be treated with alendronate for 5 years to prevent 1 new vertebral fracture. CONCLUSIONS: Alendronate effectively reduces fracture risk in postmenopausal women with vertebral fractures and low BMD, including those women at highest risk because of advanced age or severe osteoporosis. Since the risk reductions observed with alendronate treatment were consistent within fracture risk categories, more fractures were prevented by treating women at highest risk.     

Healing of tibial fractures is not impaired after acute hindlimb ischemia in rats

The influence of transient circulatory arrest on the healing of closed tibial fractures was investigated in rats by the use of a hindlimb tourniquet technique. Twenty-four animals were randomly divided into three groups. In all animals, the left lower leg was fractured and fixed with an intramedullary nail system. In the ischemic group, complete acute transient ischemia for 4.5 h and neurapraxia of the sciatic and femoral nerves were induced prior to fracture. In the neurapraxia group, the sciatic and femoral nerves were crushed with forceps before fracture. In the control group, no other intervention than fracture was made. The rats of the control group ambulated normally 3-4 days after the operation. The animals of the ischemic and neurapraxia groups resumed normal weight-bearing after about 3 weeks. After 6 weeks, all animals were killed, and mechanical strength and bone mineral turnover of the healing tibia as well as blood flow of the bone and musculature were evaluated. The weight of the tibia and the corresponding anterior tibial muscle in the ischemic and neurapraxia animals were reduced compared with the control rats. Bone mineral turnover was found to be lower in the ischemic group. There were no differences between the groups in mechanical strength nor in blood circulation of bone and muscle. In conclusion, complete, acute hindlimb ischemia for 4.5 h in rats did not cause delayed healing of closed tibial fractures.